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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Fwm a3109 (R5 / 4-03)
PrescriDed Dy Departrtrem ol Lora� Govemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is located. Q PR 9 1 Z��6
Filing Dates: 1J Real Property: During the 12 months before May 11 oI fhe year the deduction is to be eBeciive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the dedu,�citio�n is to be effective.
See reverse side /or additional instructions and qualifications. ����+�
. GIBSON COUNTY UDITOR
Applicanl (ow or contract buyer - see restrictions on reverse side)
(�1 .
Taxing DistriIX Key number / legal description Record numberO�
D � �/ — Page number � a
O - � �
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate with whom.
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If name on record is diKerent than that of applicant, indicate below: Is the property in queslion:
-- -- — — / ❑ Mobile Home (IC 61.1-�
me of mortgag�r contract seller
` Dra�ver NO. ��•
Address of moRgagee contrad selier (number and streei
� � 6.:.� z 35.,�
Name of assignee or olher owner or holder of mortgage Card \`�. ......
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Districl? Has this dedudion been requested on
county in indiana? property for current yea(? � Yes � No
,y^t COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 � 20 �`L 20 20 20 20
�
SignaWre County Auditor Date
�We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident ot Indiana and owner of the aforementioned property on March 1, 20
Signature o ners full name) Person authorized by duly executed Power of Attomey
� � or by IC 6-1.1-12-.07
ull r ident address of applicant Address of authorized person
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